Medication safety
This page is part of the wider ‘enduring standards that remain valid from previous patient safety alerts‘ set of webpages.
Medication-related incidents remain one of the most frequently reported categories of patient safety incidents, accounting for about 10% of reported incidents. National organisations such as the Royal Pharmaceutical Society (RPS), Specialist Pharmacy Service (SPS), Medicines and Healthcare products Regulatory Agency (MHRA) and other regulatory bodies provide a wide range of resources that support safe medication practice, some developed in response to past alerts.
The Medicines Safety Improvement Programme oversees quality improvement work in several key medication safety areas, including safer use of anticoagulants, problematic polypharmacy, and safer administration of medicines in care homes. Within this broader context, the enduring standards set out in previous alerts should remain an important part of every organisation’s medication safety strategy.
Identification of medication safety officers
The enduring standard from past alerts that remain valid is:
- identify a medication safety officer (MSO) and ensure contact details are kept up to date with the MHRA’s Central Alerting System (CAS) team. For more information see linking with national systems – Nominated safety officers/safety specialists.
Access to antidotes/reversal agents
Enduring standards from past alerts that remain valid are:
- naloxone is available wherever opiates are administered
- flumazenil is available wherever midazolam and other benzodiazepines are used.
However, access to appropriate antidotes/reversal agents is a principle that applies to other medications administered within healthcare, and organisations should consider these enduring standards in the wider context of supporting access to all antidotes/reversal agents their service requires, alongside supporting their safe and appropriate use.
Safe administration
Enduring standards from past alerts that remain valid are:
- ensure an ‘open system’ is not used as a container for injectable medicines
- if using a syringe to measure oral liquid medicines, only use an oral/enteral syringe, ensure an adequate supply in all appropriate clinical areas, and supply an appropriate syringe on discharge where required. This does not prevent the use of a medicine spoon or graduated measure where appropriate.
- all regular and single (bolus) insulin doses are measured and administered using an insulin syringe or commercial insulin pen device
- arterial infusion lines must be clearly identified, either with labelling or other safety solutions
Safe administration of medicines is clearly a much wider overarching principle; guidance and improvement resources produced by national organisations should be consulted including the RPS/Royal College of Nursing (RCN) professional guidance on the administration of medicines in healthcare settings.
Safe storage of medicines
Enduring standards from past alerts that remain valid are:
- Concentrated potassium is defined as 10%, 15% and 20% solutions of potassium chloride, and solutions of potassium hydrogen phosphate and potassium dihydrogen phosphate, in ampoules and vials. Storage of these solutions is restricted to pharmacy departments and critical care areas [critical care areas are defined as: intensive care units, high dependency care units, cardiac care units, other specialist critical care areas such as renal units, cardiac theatres, neonatal intensive care units and some A&E departments] where these solutions are needed for urgent use. These solutions should be stored in a separate locked cupboard and not be transferred between clinical areas but supplied directly from pharmacy.
- The storage and use of high strength midazolam (5mg/mL in 2mL and 10mL ampoules; or 2mg/mL in 5mL ampoules) is restricted to general anaesthesia, intensive care, palliative medicine, and clinical areas/situations where its use is essential; for example, where subcutaneous syringe drivers are used for end-of-life care. In other clinical areas, including those undertaking conscious sedation, only low strength midazolam (1mg/mL in 2mL or 5mL ampoules) should be stored and used.
- Sodium chloride 0.18% with glucose 4% intravenous infusion is not stocked for general use in areas that treat children. General stock of this intravenous infusion is restricted to critical care and specialist wards such as renal, liver, and cardiac units
- Epidural infusions are stored in separate locked cupboards or refrigerators from those holding intravenous and other types of infusions.
- Hospitals with transplant units (or major/highly specialist cardiac/vascular surgery units undertaking equivalent surgery) store solid organ perfusion fluids in ways that reduce the risk of confusion with other fluids administered to patients. Other hospitals should not store any solid organ perfusion fluids.
However, the principles of restricting access to medications that might be mis-selected apply to all medications administered within healthcare, and organisations should consider these enduring standards in the wider context of restricted access and best practice in design and layout of storage of medication to reduce mis-selection errors. Guidance and improvement resources produced by national organisations should be consulted, including the RPS guidance on safe and secure handling of medicines.
Safe prescribing practice
Enduring standards from past alerts that remain valid are:
- when prescribing insulin, the term ‘units’ is used in all contexts. Abbreviations such as U or IU are never used
- following a clinical assessment, a clinical professional authorises the supply of bowel cleansing medication to each individual patient before radiological or endoscopic investigations.
Two medicines that were the focus of safe prescribing guidance in past alerts have had a continued multi-agency focus with new advice that has superseded previously issued alerts:
- methotrexate: MHRA guidance supersedes the previously issued alert
- valproate: a Valproate Safety Implementation Group has been established and will provide guidance that supersedes the previously issued alert. Organisations should implement this guidance as soon as it is published.
The principles of safe prescribing apply to all medications prescribed within healthcare, and the enduring standards described above can be applied to other medicines (eg using ‘units’ when prescribing heparin and other medicines) or clinical situations. Organisations should consider these enduring standards in the wider context of guidance from national organisations including good prescribing practice, the need for continuity of presentation, and awareness of regulatory restrictions for certain medicines; including the need to ensure pregnancy checks and pregnancy prevention plans for all types of medications where teratogenic effects require this.
Medication (including infusion) labelling
Enduring standards from past alerts that remain valid are:
- clearly label infusion bags and syringes for epidural therapy with ‘For Epidural Use Only’ in a large font
- use clearly labelled epidural administration sets and catheters that distinguish them from those used for intravenous and other routes of administration
- the following warning should be prominently displayed on the label of all vinca alkaloid doses: ‘For Intravenous Use Only – Fatal If Administered by Other Routes’.
However, principles for medication labelling apply to all medications purchased, manufactured, and dispensed within healthcare. Organisations should consider these enduring standards in the wider context of best practice guidance on the labelling of medicines; including the information that is critical for the safe use of medicines, and the format and style of the information provided, to avoid confusion between look alike, sound alike (LASA) medicines.
Go back to the main ‘enduring standards that remain valid from previous patient safety alerts‘ webpage.